The Birth Activist
Who are you, what do you do and where do you work?
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Hi - I'm Jo Dagustun. Around my personal commitments (family, friends, local community), I try to spend near enough all of my free-time at the moment working with the aim of making birth better for woman and their families. I see this period as pay-back time to the taxpayer, who very generously funded all of my academic study as well as my early career in public policy. I’m happier when this does not leave me out of pocket in cash terms, but I donate my energy freely.
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I do this birthwork almost exclusively on an unpaid basis, intervening at a number of scales, from the local to the global. So one day I might be working in my local area to try to strengthen local arrangements for involving service-users in local maternity service commissioning and provision decisions. Another day I might be involved with national groups in discussions about the regulation of midwives.
Recently I have been focussing on the national Better Births vision and its implementation across England, where I believe that developing a common understanding of the key role that local activists must play in this process is a really important priority. Recently I took on the mammoth task of leading local work to review and comment on our local Better Births implementation plan, and I really hope that the women and families of Greater Manchester and Eastern Cheshire benefit as a result of that intervention.
More generally, I think about how global circuits of knowledge work to destabilise understandings of birth as a healthy physiological process and - linked to this - of effective maternity care as a crucial part of a successful public health agenda: the WHO and others are doing some great work around this, of course, but there is scope for many more of us to play our part.
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Every day brings new issues as well as the continuation of ongoing projects. Importantly, every day involves networking with fellow birth activists in some way, whether remotely or face-to-face. I am linked in to a wonderfully supportive community of people in this weird world of ‘institutionally unaligned’ birth activism. We regularly turn to each other for advice, collaboration and companionship, and this is hugely important to me. Without a strong and supportive group of peers, I would not be making my contribution in this field: there are just too many unpleasant kick-backs along the way, that would just be too hard to deal with if I was working solo.
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Perhaps the key theme running through my work is my desire, especially in the UK context, to bring people together to improve birth. There are so many people from many different backgrounds actively investing in this project at the moment. That is brilliant, but at the same time, all of the different initiatives and organisation can become a little overwhelming, they can compete for the limited resources available and sometimes come into conflict. They each have their own particular areas of interest and expertise, and each is therefore really important. But too often, I come across instances where we seem to be working in silos, not fully appreciating the connections between our work. And disappointingly, I also see also much conflict amongst ourselves, undermining each others’ work, rather than acting as a harmonious community of birth activists working collaboratively towards a set of common goals. I really believe that working more effectively together would mean that we would all individually be stronger, and - most importantly - produce better results for women and families!
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How do you think staff and services may (inadvertently) influence a woman's traumatic experience?
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Hugely. I cannot claim a personal traumatic birth experience, but my research has really opened my eyes to the wide range of ‘trouble’ that women and their families routinely run into during their contacts with the maternity services. I was not looking for this issue, but it soon became central to my work. For some women and families, these experiences can be put to one side, and they just get on with their lives, but for others, I have seen how negative interactions with individual staff and ‘the system’ can really destabilise a woman and her family and have a long-lasting and/or high impact traumatic effect. I really believe that it doesn’t have to be like this, and whilst efforts to support women and their families who have been traumatised in this way are incredibly important, I’d also like to make sure that we are working hard to prevent such trauma - wherever possible - in the first place. In part, this is about bringing women’s wellbeing back into focus as a key maternity outcome: measured outcomes must never be solely about future population health, for example, for in that way lies scope for a great deal of injustice.
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What role do you think antenatal care and education has in the potential to reduce trauma (without increasing fear)? Do you think women and their partners could be better prepared for birth?
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I think it has a really important role, and I would like to suggest that the primary locus for such action must be in the context of an ongoing mutually respectful and trusting relationship between women and their ‘key account manager’ from the maternity services. This key account manager will usually be a midwife who will be expected, in the normal course of events, to support the woman and her partner/ family in person through pregnancy, birth and postnatally. I think that this ‘continuity of carer’ approach sets up really important incentives: unless you are caring for a woman throughout her maternity journey (and maybe even through successive maternity journeys), each individual interaction can so easily become focused on the current transaction, rather than located in a deep understanding of that woman’s individual resources and needs.
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Beyond this crucial relationship, which I think should form the bedrock of a safe and effective maternity service, I am really impressed at the moment by the huge growth of peer-to-peer resources for women, whether this be via books, free-to-access discussion groups or social media activity. I think this has the potential to be hugely valuable, but at the end of the day, I’m not sure that any amount of preparation will prepare most woman for some of the poor practices and processes that they might unexpectedly encounter in the UK’s maternity care system. And I’m not so clear about how well such peer-to-peer initiatives are reaching beyond ‘the usual suspects’: I’d like to see a more determinedly socially-inclusive plan of action. Paid staff have an incredibly important part to play here, I think, and as part of this group antenatal spaces facilitated by midwives and others could be hugely more effective, for example, if properly conceptualised and resourced.
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There seem to be two 'routes' to trauma - an emergency experience which is physically and emotionally traumatic or a lack of compassion during care. In your opinion, is there anything that could prevent or reduce trauma in an emergency situation?
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Yes - let’s talk about emergency experiences … When I listen to women talk - and I am listening as a social geographer and lay person, of course, not a healthcare professional - there actually seem to be very few instances of true emergency situations, driven by a totally unexpected pathology. (More often, this is just how unplanned events are categorised by healthcare professionals, or how they end up, following what many women and their families might experience as a series of baffling delays.) I would also suggest that many situations which end up as ‘emergencies’ could have been handled so much better from the start. We need to really analyse how our system works to produce these emergency situations, as I suspect that such an analysis would demonstrate how a different system configuration would lead to fewer such events. For me, time and time again I hear of women encountering complete strangers in early labour, for example, which can lead to all sorts of misunderstanding, mistrust and anxiety - which then has obvious knock-on effects for the progress of physiological labour: in 2018, I would say that it is just not good enough that women are not accompanied through this crucial stage in their maternity journey by a known and trusted professional.
The other route is women and their partners feeling that they were not cared for with compassion during their experience. I'd love to hear your thoughts on this?
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I am convinced that very very few healthcare professionals turn up at work each day with the intention of delivering uncompassionate care! But when I listen to women, this is sometimes hard to square with the accounts I hear. For me, I think this comes back to having in place the right number and configuration of appropriately skilled, experienced and motivated maternity care staff, who are all intensely focussed - working well together as a highly-performing team - on providing high quality care to each individual family they encounter. It’s all in the Better Births vision!!! It also brings me to the crucial importance of a strong mother/midwife relationship, where that individual midwife takes responsibility for ensuring that all maternity care interactions with that woman are effective, safe and rooted in compassion.
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What do you wish women and their partners knew about birth?
In the UK context, I wish that they knew that they had a skilled companion to journey alongside them through pregnancy, birth and the postnatal period. A trusted companion, with whom they could discuss their dreams, fears and uncertainties. Who would be there for them every step of the way, drawing in other members of a well-functioning and well-resourced multi-professional team where necessary to meet the specific needs of that individual woman and her family. This, of course, is the vision at the heart of Better Births, and WE ALL need to work together to make this happen.
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How do you think we can make birth better for everyone?
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I think that we really need to improve our collective understanding of how wonderfully effective the physiological process of birth can be, if only we supported it properly. Instead, expectations of that physiological process are low, with some women even wanting to divert from that physiological process in the absence of any indicators that it might not go well (and rightly so, especially where this is done with the aim of women protecting themselves from their lived experience of emotional and physical harm suffered in previous encounters with the maternity care system). I’d like to give another minor example of this need for a greater understanding of the physiology of birth, not trauma focussed this time: it took me four births to realise that my body was quite capable of birthing my placenta without medical assistance! Our understanding and expectations of our own bodies are really very low indeed. It is quite incredible really, that we got to the moon in the year of my birth, but 50 years later many women in the UK are still feeling grateful and lucky that we and our babies are alive following birth.
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